The POP Act (Patients Over Profit Act) prohibits any entity from simultaneously owning or controlling both health insurance companies and specific types of healthcare providers that participate in Medicare. Its core purpose is to prevent conflicts of interest where insurers could prioritize profits over patient care by steering Medicare beneficiaries toward provider networks they own, potentially driving up costs or reducing care quality. The bill targets vertical integration in healthcare—particularly private equity-owned medical groups and insurer-provider conglomerates—by forcing divestment within strict timelines. If enacted, it would significantly reshape Medicare Advantage and Part D markets by barring common ownership, imposing financial penalties for violations, and redirecting ill-gotten revenue to community health needs. This could reduce insurer influence over treatment decisions but may also disrupt existing integrated care models.
Key Points
- 1Ownership Ban**: Makes it illegal for any person or corporation to own both a "health insurance issuer" (e.g., Medicare Advantage or Part D plan) and an "applicable provider" (e.g., physician practices, clinics, or management services organizations contracting with them), excluding hospitals, pharmacies, and medical equipment suppliers.
- 2Mandatory Divestment**: Requires entities violating the ban to sell off either their insurance business or provider network within 2 years for pre-existing ownership structures (or 1 year for new acquisitions after enactment).
- 3Civil Penalties & Revenue Disgorgement**: Authorizes the FTC, DOJ Antitrust Division, HHS Inspector General, or state attorneys general to sue violators, forcing them to stop the practice, divest assets, and surrender all revenue earned from Medicare services during the violation period.
- 4Medicare Contract Enforcement**: Amends Medicare law to bar the government from contracting with Medicare Advantage or Part D plans that violate the ownership ban, treating their payment claims as "false" under federal fraud statutes.
- 5FTC Oversight**: Requires all divestments to undergo antitrust review by the FTC and DOJ, with divestment deadlines paused during this review to ensure competitive outcomes.